TJC Proposes New Requirement on Distinct Identification in Newborns

PUBLISHED: Mar 8, 2018
Relevant to: Critical Access Hospitals, Hospitals

The Joint Commission (TJC) is seeking comments on a proposed new Element of Performance (EP) for their National Patient Safety Goals chapter. The new EP will be applicable to the Hospital and Critical Access Hospital accreditation programs and addresses identification methods for newborns after delivery.

The proposed new EP 3 would be added to NPSG.01.01.01 which requires Hospitals and Critical Access Hospitals to use at least two patient identifiers when providing care, treatment and services. EP 3 would be specifically for hospitals and critical access hospitals that provide obstetric services, specifically labor and delivery, nursery care, and/or NICU services.

The proposed EP 3 will require a distinct naming system for accurate newborn patient identification. TJC gives the following examples:

  • Mothers first and last names, newborn gender (Smith, Judy Baby Girl)
  • Standardized practice for identification banding (use of barcoding, using two-body site identification)
  • Establishing communication tools for staff (checking for two patient identifiers prior to medical record entries; visually alerting staff with signage noting newborns with similar names)
  • Using a second person prior to high-risk procedures to positively identify patient (e.g., using a second medical professional or approved family member to verify patient name or medical record number)

TJC is accepting comments on this new proposed EP through April 17, 2018. Follow the link below to review the proposed EP in detail and for comment submission instructions.

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